Obamacare Geographic Implementation Overview: Wednesday Focus for October 29, 2014

Key takeaways:

1. Having a state government that expands Medicaid is, of course, overwhelmingly the most important factor: look at Kentucky-WV vs. Tennessee-Virginia, or Arkansas-Missouri.

2. A state government that tries to hide the existence of the exchange-marketplaces from people can (largely) do so, and can cause a huge amount of damage in implementation: look at Wisconsin, Kansas, or Montana.

3. Even in states that did not expand Medicaid and where the state government did not lift a finger to inform people of the exchange-marketplaces, Hispanics have been signing up for insurance in numbers significantly greater than I had expected–look at the Texas-Mexico border.

4. With respect to what remains to be one, look at the Confederacy! (Minus Medicaid-Advantage Arkansas, of course.) At the end of the nineteenth century the Confederacy was taxed to provide pensions for the widows and orphans of Union-Army Civil-War veterans: now we have a similar pattern underway–although this time it is voluntary, produced not by northern Unionist-Republican votes but by southern neo-Confederate-Repubublican votes.

5. Given how broadly the money from Obamacare flowed not just to the poor and previously-uninsured but to all the different parts of the medical-industrial-financial complex, I am still amazed by how not ideology–ObamaCare, remember, is in its essentials a Cato Institute production–but mere partisanship (and anti-Obama racism?) trumps the material interest of the money flows. Given the centrality of the medical-industrial-financial complex to so much of so many local economies, this extremely sharp regional cutting-off-one’s-nose is an extraordinary shock.

6. What SL said about NFIP vs. Sibelius: Scott Lemieux: A Disgrace Even By Roberts Court Standards: “The effects of John Roberts re-writing the ACA’s Medicaid expansion are felt in Mississippi…. ‘”We work hard at being last”, said Roy Mitchell, the beleaguered executive director of the Mississippi Health Advocacy Program, when we met in Jackson. “Even a dog knows the difference between being tripped over and being kicked”‘. This reflects an infliction of pain and suffering and death than was eminently avoidable. If you’ll forgive me for reiterating, it’s nearly impossible to overstate how terrible this decision was. It would be one thing if this denial of access of medical care to millions of people was enforcing some explicit constitutional provision, but it wasn’t. If this judicially invented at least protected some meaningful individual liberty interest it might be a little more understandable, but it doesn’t. At best, the lives of millions of people have been made worse–with consequences up to and including death–in order to prioritize inferential states’ ‘rights’ [to ‘equal dignity’] over human rights. But here’s the kicker: Sebelius does not even provide any significant protection for state autonomy. Congress remains free to create a Medicaid program that requires everyone up to 138% of the federal poverty line to be covered and makes all Medicaid funding contingent on meeting these conditions. It simply would have to structure it by formally repealing the previous Medicaid and replacing it… thus evading the Supreme Court’s newly minted requirement that existing funding can sometimes be made contingent on accepting new conditions and sometimes can’t and we’ll let you know ex post facto…. The fact that so much misery was created for so little should permanently shame the justices who voted for it. It’s judicial review at its least defensible.”